Emegency Departments That Lag

Time to treatment equals quality for much of emergency medicine.  It’s also the easiest way to decide whether an ED is any good.  Missed diagnoses, errors of judgment, and clinical mistakes can be hard to spot by comparison.

Emergency Departments That Lag

1.  Long Line up at triage –

The most at-risk patients stand in the line-up for triage.  Every day, patients walk in with a deadly process inside of them.  Until they have been seen, they are unsafe.  A line up to be seen is indefensible.

2.  Long triage process –

Triage should be sorting; not a primary nursing assessment.  Patients need a diagnosis and treatment.  In most cases, this means getting patients and physicians together as fast as possible.  A long triage process does not add value for patients.

3.  Long Line up at registration and long registration process –

Registration – getting a chart made – does not add value for patients; it only delays care.  It must be short!

4.  Packed waiting room –

There is no reason for patients to EVER wait in the waiting room.  Please argue in the comment section below if you disagree.

5.  Patients must repeat their story over and over and over.

Providers should quickly check what others have recorded, verify the facts and ask additional questions.  Starting over with every provider drives patients nuts.

6.  No discharge excellence

Patients should leave the ED with copies of lab and radiology reports, written discharge instructions (if necessary), and clear instructions for follow-up and return visits to the ED.

7.  Dismissive attitude

Patients should be welcomed to the ED for ANY complaint.  No complaint is trivial for a patient.  We – healthcare providers, media, government, all of society – seem to think healthcare would be just fine if it weren’t for all the patients.  Besides being unwelcoming non-verbally, there’s a big difference between “Why are you hear today?” and “How can I help you?”

Rules in case you get sick:

Don’t go to your family doc unless you’ve tried something yourself first.

Don’t go to your specialist unless you go to your family doc first.

Don’t go to the ED unless you’ve gone anywhere else first.

Don’t go to the ED unless you are nearly dying.

If you are dying, you shouldn’t go to the ED because we can’t do anything for you…

 

Excuses

But all our beds are full of admitted patients!

Definitely the most popular excuse, admitted patients definitely make it almost impossible to provide emergency care some of the time.  But, even with admitted patients blocking beds, patients should still be brought into the ED and seen on exam tables.  If they can wait on chairs in the waiting room, they can wait on chairs inside after they’ve been assessed.

Thankfully, Ontario has started to hold hospitals accountable for getting admitted patients out of the ED, and up to the wards.

Who owns morale?

Management owns operations; staff owns morale.  Sure, you can crush morale in even the most engaged staff, but blaming management for staff attitudes will mire an ED in under-performance.  Staff control their own morale, and it must be part of performance management.

How does your ED stack up?  As a patient, have you researched your local EDs to see which ones to avoid?  

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What You Need to Know to Improve Patient Flow at Triage

Modern triage = patient sorting + a boat-load of protocols and ‘value added’ steps.

Napoleon’s surgeon seems to be the first provider to try a sorting process for crowds of patients.  He wanted to quickly sort which wounded soldiers were most likely to return to battle, so he could provide care for them first.  Historical triage got soldiers back into action while seriously wounded soldiers were left to die.

Nice.

In the olden days of emergency medicine (30 years ago), patients could usually be seen soon after registration.  They were brought straight in, seen by a nurse and a physician soon after.  In the 1990s in Ontario, the ED became a favourite spot to park admitted patients when the inpatient wards became ‘full’ as defined by staff working on the wards.

Around this time, triage turned into primary care nursing for new arrivals and the crowd of patients warehoused in the waiting room.

This was never meant to be.

Triage must be rapid sorting or it’s not triage at all.

Long interviews, multiple forms, medication reconciliation, past medical history, allergy lists, infection control screening, extensive sets of vital signs, patient examination, wound inspection, and answering questions about waits, parking, directions and vending machine locations – modern triage redefined the term ‘triage’.

Maybe that’s a good thing?  Surely, all the added work being done by modern triage was started for a reason?  Maybe patients want to come to the ED to get a really thorough triage?

NO!

Patients come to the ED to get a diagnosis and treatment.  Anything that stands in the way of diagnosis and treatment does not add value for patients.

Triage should add value by getting patients to the care they need as quickly as possible.  We should resist anything that stands in the way of patient care.  Quality care depends on timely assessment and treatment.  Triage adds value only if it facilitates timely care.  Triage should never bottleneck flow; there should never be a line-up to see the triage nurse.

We must unload all the duties we’ve piled onto triage, if we are serious about improving patient flow.

If hospitals insist on running waiting rooms like a clinical areas, patients would be better served by assigning nurses to care for the patients in the waiting room instead of shackling triage nurses with non-value-added work.

Does triage add value in your hospital or does it delay care?  Is there a patient line-up for triage?  

Please click Leave a Reply or # replies below.

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ED Stretchers Boarding & Flow

Racing a patient through the emergency department on a stretcher makes exciting TV.

Physician and Nurse Pushing Gurney

But for most EDs, stretchers are the enemy, because stretchers crush patient flow.

Most patients walk into the emerg and walk home – less than 15% get admitted in Canada. There’s no need to force patients to lie on a stretcher unless absolutely necessary.

Patients sit for hours with serious or potentially life-threatening conditions in most waiting rooms.  It’s much safer to get them in and examine them on an exam table inside the ED even if it means they have to sit in chairs during investigation and treatment.

Sure, some patients need stretchers for the duration of their ED visit.  But for most patients, if they can walk, they can sit.  If they can sit, they do not need a stretcher.

Stretchers enable dysfunctional behaviour that makes patients wait.

Stretchers –

1. Attract admitted patients boarding them for days.

2. Act like real estate for ED patients.  Providers assign one ‘lot’ for each patient.

3. Make patients immobile even if they walked into the ED.

4. Allow providers to ‘tuck patients in’, rails up, safe and sound.

Exam tables increase flow by –

1. Removing a spot for admitted patients.  Exam tables are like OR tables:  OR tables are for surgery, not admission.

2. Providing a shared resource for all, not an assignment for one.

3. Getting patients to move, which fosters flow.  Exam tables don’t have wheels.

4. Keeping providers moving with patients.  Exam tables are unsafe without a provider present.  Patients spend minutes on an exam table instead of hours on a stretcher.

Dozens of patients cycle on and off one exam table, whereas one stretcher serves only a few patients per day.  If the average patient spends 6 hours in the ED, each stretcher can serve, at most, up to 4 patients per day and usually far less.

If you haven’t done so already, replace as many stretchers as possible with exam tables.  If exam tables are only found in the minor treatment area, you don’t have enough!

Like any change in historic process, providers realize how attached they are to stretchers when you start asking them to use exam tables instead.  But without building EDs twice the size, we cannot continue insisting that all patients, except the lowest acuity, get seen on stretchers.   Staff support exam tables once they see how much  flow improves; it’s the best way to get patients seen and treated promptly in today’s over-crowded EDs.

Stretchers ruin patient flow, function as a reservoir and promote dysfunctional behaviours. Get rid of them where ever you can!

 

Do admitted patients block your ED stretchers?  Do all your ED patients currently in stretchers actually need to be in one?  Are they blocking flow making other patients wait for care?  Why not replace some stretchers with exam tables?

 

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